The Politics of Healthcare

Kimberley Strassel

In 1993, millions of Americans made the acquaintance of Harry and Louise. The brainchild of the U.S. insurance industry, the fictional TV couple could be seen sitting at their kitchen table worrying about the bureaucracy and cost that would accompany the Clinton Administration’s healthcare plan, known as the Health Security Act.

Clinton supporters were outraged by the lobby effort and Hillary Clinton herself scorned Harry & Louise as “homey kitchen ads.” But the couple served their immediate purpose, warning American voters about the perils of government-run healthcare, and provoking a backlash that helped sink what became known as “HillaryCare.”

In hindsight, it’s clear Harry and Louise played a bigger, long-term role in the debate as the power of their message fundamentally reshaped the politics of healthcare. Both Democrats and Republicans drew lessons from the Harry and Louise success, lessons that continue to reverberate today and are playing out in the 2008 elections.

For Democrats, the ads resulted in a rebuke of the party’s first big, modern push to dramatically increase the role of government in healthcare, which was institutionalized with the Republican takeover of Congress in 1994. The blowback scared the party into inaction and later convinced it to fundamentally revamp the language, the pace and the approach to its drive for more government-run care.

For Republicans, the ads led to a false sense of security. Convinced Americans were against Canadian-style healthcare, many GOP politicians put the issue aside. While conservative think tanks continued to pump out free-market solutions to U.S. healthcare failings, few Republican politicians took up these reforms. The party in 2006 lost its control of Congress, weakening its ability to lead on the healthcare debate just as the need for leadership once again became urgent.

Throughout all this, the U.S. healthcare system—a system that is in many ways free and innovative but is also disabled by poor government policy—has limped along. Americans have seen health insurance premiums double between 1996 and 2006. Employers are sinking under healthcare costs, cutting services and payments. State governments are struggling to pay for expanding healthcare entitlement programs. The ranks of the uninsured continue to grow.

This downward spiraling of today’s hodgepodge system has reopened the debate, with Americans now demanding Washington do something. The bank-breaking question is: What? Both parties have committed themselves to fundamental overhaul, but the fact remains that America’s two leading political parties have starkly different visions of an ideal healthcare world. Will the U.S. healthcare system be taken rightward, toward greater, market-driven innovation, or leftward toward greater government dominance?

Despite all the campaign promises, political realities suggest it will be unlikely that the next president will be able to quickly pass sweeping healthcare reform. This is, in fact, good news. A delay would allow proponents of free-market reform more time to craft a sound solution, and to make their case to American voters.

Reality versus the DreamsUnderstanding the politics of healthcare first involves understanding the healthcare system itself: What it looks like today and how conservatives and liberals would change it to create their ideal world.

Our modern healthcare system has its roots in World War II. Companies couldn’t compete on wages (which were controlled) for scarce labor, so they competed on benefits such as health care. The federal government later formalized this practice by making employer expenditures tax deductible, although it failed to do the same for individuals. The government has also created several government-insurance programs—namely Medicare, Medicaid, and the State Children’s Health Insurance Program—which continue to grow and cover more Americans.

Bad tax policy and growing government involvement in the healthcare market—combined with a hodgepodge of poorly designed legislative “fixes” and regulations over the years—have resulted in market distortions in what has otherwise proved the world’s most innovative healthcare system.

In the corporate world, tax deductions for many years allowed companies to offer gold-plated health plans that covered most every aspect of care (save minimal co-payments). Consumers have, as a result, had little reason to make choices about what is cost-effective or necessary, which has contributed to double-digit annual increases in health-care inflation.

Those prices have come back to whack companies, which are struggling to keep up with costs. Every dollar they spend in healthcare is one less dollar that might go to investing in their companies or paying their workers more in wages. And, as healthcare prices have become financially debilitating, companies have responded by passing more of the burden on to their employees via higher premiums, fewer services and lower wage increases.

Spiraling corporate health-care costs have also begun to bleed into the wider economy. Consider Detroit. It is now estimated healthcare costs add some $1,500 to the price of General Motors car. This is an expense the Big Three cannot afford in today’s fiercely competitive auto world, and it has helped to dampen sales and contributed to Detroit’s layoffs and financial woes.

Corporate-provided managed care also takes away choice. Companies choose their insurance providers, not employees. Individuals are stuck with what’s on offer, plans that are usually one-size-fits-all and that can change from year to year as a corporation searches for better deals. Individuals also lose their network of doctors and plans when they switch jobs and go to a company with a different insurance provider and a different network.

Side by side with this unruly corporate system are enormous government health-insurance programs such as Medicare and Medicaid (both created in 1965) and the State Children’s Health Insurance Program (created during the Clinton Administration). These programs have resulted in a flood of new healthcare spending that has pushed up prices. The federal government has estimated that each additional $1 of Medicare spending yields about 35 cents of additional care. The rest goes to inflating prices.

Government programs also crowd out private insurance, resulting in fewer people paying into a private insurance system and raising premiums for those who do remain in the private insurance world.

As for those Americans who do not receive either corporate health insurance or government aid, health insurance is almost beyond reach. Government tax policy is distinctly unfair: the tax subsidy that goes to corporations is not afforded to individuals. Whereas a corporate employee is provided health insurance as a benefit, and tax free, the rest of America must purchase its own and with after-tax dollars. The cost of these policies is also prohibitive, in no small part because of the health-care inflation that accompanies corporate care and government services.

State and federal rules also pump up the price of health insurance, or discourage people from obtaining policies. Many states have “mandates” as to what insurance companies must provide policyholders—chiropractic care, wigs for cancer patients, infertility treatments. Some states have “guaranteed issue” laws that allow people to wait until they are sick and then buy insurance. Others have “community rating” requirements that prevent insurers from charging different prices to people of different ages and health status. All of these rules and regulations add costs, which are factored into policy premiums. Consumers meanwhile must buy insurance in their home state, rather than shop for better deals in jurisdictions free of such requirements.

Meanwhile, some 45 million Americans do not today have health insurance. Liberal politicians suggest this is the fault of high insurance costs. But many of the uninsured can afford to buy coverage but choose not to (in particular, the young) or are people who qualify for Medicaid or other government programs, but who are not enrolled. And why would they? Hospitals are required to treat all who show up and many states allow people to buy insurance even after they are sick.

This piecemeal system is unfair and unworkable. One group of Americans (those working for bigger companies) receives its care largely free, though the recipients have little choice over their policies and few incentives to self-ration care and keep down prices. Another group (almost half the country) gets care from the government, which presides over an unwieldy bureaucracy that also drives healthcare inflation. Another chunk of America is left to fend on its own, to buy individual policies that bear the burden of bad tax and government policies. Yet another remains uninsured and fails to pay its “share” of insurance costs, since there is no compelling reason to do so.

Both Republicans and Democrats say they want to “reform” this system, though their visions for what counts as an “ideal” system are polar opposite. That in part stems, unsurprisingly, from completely different views about what health care is, and what reform should accomplish.

For most liberals, today’s healthcare ideal is a single-payer system. They would like one entity to pay all American health bills and they want that entity to be the United States government. (Some on the left would go so far as to advocate for completely socialized medicine, in which healthcare is owned, operated and financed by the government, but this is currently a political non-starter with the American public.)

What drives liberal support for a single-payer system is philosophy: Single-payer proponents believe health care is a “basic human right” and that it should therefore, as a matter of principle, be provided by the government. They also believe that the care that is provided should be “equal” no matter an individual’s economic well being, background, geography, employment or special circumstances.

Single payer proponents also suggest that a national insurance program would solve today’s healthcare-problems—reining in healthcare inflation, insuring more Americans, cutting back on bureaucracy. But promoters have struggled to make that case for the simple reason that the world has plenty of single-payer systems that don’t solve those problems, and in many cases create worse ones.

Canada may be the best example. To the extent Canada, or other single payer countries, have kept down healthcare costs, they have done so by rationing healthcare. The infamous Canadian waiting lists, where hundreds of thousands of people are currently on hold for basic health-care procedures, is one result. Canada lacks vital equipment and offers hundreds fewer prescription drugs than the United States. Canada also holds down costs by restricting payments to doctors and health professionals. This discourages talent, innovation and the number of people going into the medical profession. Wasteful bureaucracy is still prominent in the Canadian system.

Politicians on the left have unsuccessfully tried to explain away these failings. But their bigger problem is that countries like Canada undermine concept of single-payer systems. The Canadian government may offer healthcare as a basic “right,” but that right is meager indeed. As the Canadian Supreme Court ruled in 2005—in a suit brought by a patient who’d been told he’d have to wait a year for a hip replacement, and that it was illegal for him to purchase private health insurance—“access to a waiting list is not access to healthcare.” As for fairness, the thousands of wealthier Canadians who routinely come to the United States to receive better or more immediate care prove that it is impossible to “equalize” humanity.

Conservatives, for their part, have come to an ideal vision of healthcare that is premised in part on philosophy and in part on a desire to offer practical solutions to day’s health-care failings. Their broad package of ideas has come to be known as “consumer-driven healthcare.”

The idea behind consumer driven healthcare is of a piece with other conservative beliefs. At its core is the conviction that individuals are best suited to make decisions about their needs. What they need is a freely functioning and competitive private market that can provide choice and innovation. That innovation is what has driven past medical advances and kept America on the cutting-edge of healthcare, but is now at risk from greater government regulation.

Consumer-driven healthcare would require a big overhaul of the tax system. The government would axe the corporate subsidy and replace it with a tax deduction or tax credit for individuals. Individuals would then use this money to purchase their own health insurance, choosing a plan that worked best for them at their particular time of life or circumstances. In this ideal, Americans would again view health insurance the way they view other types of insurance. Individuals would pay out of pocket (self-insure) for most of their routine primary care or diagnostic tests. Insurance would be held in reserve for unexpected or costly procedures.

Those policies would be less expensive than current offerings. Making Americans financially responsible for more of their care would lead to wiser health-care buying decisions and would help hold down inflationary healthcare costs. A more competitive health insurance market--the result of millions of new individuals flooding into buy policies with their individual tax dollars--would also lower healthcare insurance premiums. The federal government would allow Americans to shop in any state for the best or most affordable health insurance plan, which would inspire further competition. Americans would meanwhile be able to set up “Health Savings Accounts” in which they could divert tax free dollars (or potentially get contributions from employers) to help pay for out-of-pocket medical costs. The contributions would roll over year to year, allowing Americans to save health dollars for a future point in life when their healthcare expenses were larger.

A widespread tax benefit would encourage more Americans to buy into the health-care market, reducing the number of uninsured. These policies could be carried from job to job or even retained during periods of unemployment. Both Medicare and Medicaid would be reformed to allow enrollees to access private health insurance, which would reduce government “crowding out” of private insurance, while simultaneously encouraging wiser health-care spending and help to bring down costs.

Critics on the left complain these benefits are hypothetical and will not materialize. But there is no reason to believe they will not. Free and competitive markets have driven down costs, increased quality and expanded choice in every other industry to which they’ve been applied. It is true that a free-market approach will not result in totally “equal care.” But we do know from free-market successes in other areas that it will do the most good for the most people, while also preserving cherished American beliefs in choice, responsibility and private solutions.

Politics, As UsualIdeals are one thing, Washington is another. The political realties of Washington, coupled with the brutal 1993-94 Clinton healthcare battle, have caused both political parties to reevaluate their political health-care strategies. The past 15 years have been marked by a much more politically calculated and incremental approach.

Democrats, having lost not only the Clinton initiative but control of the House of Representatives, regrouped into a defensive position. Throughout their years in the minority, the party’s primary political focus was to stymie any Republican efforts at more free-market reform, particular in the area of government entitlement programs.

Arguably their greatest success was the 2003 fight over a new prescription drug benefit for Medicare. At least some Republicans went into that fight determined to insist on sweeping Medicare reform as a price of adding a limited drug-entitlement program. The initial conservative plan was to tie any drug benefit to senior participation in a “premium support” model—in which seniors would apply a government contribution toward the price of a private insurance plan. Another GOP proposal was to require seniors who stayed in traditional Medicare to pay a little extra if it cost more, a strategy also designed to encourage more private insurance use.

These smart proposals ultimately went out the window as a Republican leadership panicked over the political fallout of not “compromising” with Democrats to provide a big new prescription drug entitlement. Democrats suggested Republicans would be to blame if millions of seniors didn’t get help with prescription drug prices and the GOP failed to counter. The party instead largely abandoned its reform demands and agreed to make Americans pay for a huge new government liability attached to a largely unreformed Medicare program.

Since that victory, and in the face of rising public angst over the healthcare system, Democrats have also started going back on the healthcare offensive. This time, however, their approach has been dramatically different—both in rhetoric and action.

What Democrats took away from the 1993 debate is that Americans—worried as they are with today’s crumbling healthcare system—remain terrified of dramatic changes to that system. They’ve also understood that U.S. citizens care about choice and control over their healthcare decisions and are wary of complicated, or one-size-fits all government solutions. The party leadership absorbed this and switched gears: Rather than tell Americans what kind of healthcare they needed and propose the government supply it, they’d instead highlight the inadequacies of today’s system, and offer government up as one alternative among many.

Out of this approach was born the Democrats’ battle cry of “universal care.” A focus on how many Americans today don’t have health insurance has continued to allow the party to decry private insurance and Republicans. They have claimed today’s 45 million uninsured Americans stem from “greedy” insurance companies, “waste” or “fraud,” expensive pharmaceuticals, and a faltering economy.

It also allowed them to suggest that the only way to lower today’s numbers of uninsured is for government to step in to offer its own “affordable” health insurance for those who presumably have no other option. Democrats are careful to say that Americans will not be required to use this new national health plan, but that consumers will simply have the “choice” of buying it rather than a policy through a private insurer. Democratic presidential nominee Barack Obama has made the promise of such a new government plan a central plank of his candidacy.

The promise of a more limited government insurance program is nonetheless still in aid of the ultimate goal of one single-payer system. Rather than inflict a single-payer system on America in one fell legislative swoop, the Democratic Party’s new strategy is to incrementally expand government financing of healthcare, drawing ever more Americans under the government’s wing, until such a point that switching to single-payer is no longer such a big political leap. Call it a single-payer system, on an installment plan.

The party is already busy using its majority to enact this broad strategy. The most notable example began in spring of 2007, soon after Democrats took control of the House and the Senate. The State Children’s Health Insurance Program, Schip, was created in 1997 and was designed to provide health insurance to children whose families weren’t poor enough to qualify for Medicaid. The program must be reauthorized every 10 years and Democrats announced their intention to use that reauthorization to dramatically expand the size and scope of the program.

Schip has already grown far beyond what anyone once imagined. The program began as a $40 billion block grant that provided states with a fixed annual contribution. The states match these funds, which were supposed to go to children of families making up to twice the federal poverty line. But states were also allowed to design the rules. Many applied for federal waivers allowing them to vastly exceed the initial federal requirements for qualification for the program, expanding the income threshold for those children who qualify, or upping the age limits. Some states expanded Schip to cover all children, regardless of their family income. Unsurprisingly, states then claimed they needed more federal money.

The Democratic proposal was to give it to them, and much more. Whereas President Bush wanted to add $4.8 billion to the Schip budget, bringing it to $30 billion over the ensuing five years, Democrats demanded an additional $50 billion to $60 billion. The House Democratic bill, unveiled in August 2007, proposed to make the program a permanent entitlement, rather than a program that must be reauthorized every 10 years. It offered “bonus payments” to states that enrolled more children, encouraging the program to expand even further. The bill relabeled “children” as anyone under the age of 25. And it relabeled “low income” as any family making up to 400% above the poverty level, or approximately $82,000 for a family of four.

Hoping to kill the proverbial two birds with one stone, Democrats also wanted to pay for a portion of the new Schip spending by gutting the modest Medicare reforms Republicans managed in 2003. They would have done this by starving the private insurance-based Medicare Advantage program of money, resulting in more meager care, and thus fewer enrollees. In sum, the bill would have moved untold numbers of older Americans out of the private insurance world and back under government insurance, while adding untold numbers of younger Americans to the government-finance Schip rolls. The only thing that narrowly prevented this was President George W. Bush’s veto pen.

Even as Democrats were working to expand Schip to cover older Americans, party leaders were floating proposals to have senior citizen programs such as Medicare cover younger Americans. House Energy and Commerce Committee Chairman John Dingell was reported to have floated the idea of allowing the Big Three auto makers to enroll workers in Medicare at the age of 55, or 10 years earlier than allowed by law.

Republicans, for their part, have only recently been working to get back on top of the healthcare question. Heady with their victory over the Clinton initiative in 1993, many in the GOP were only too happy to shelve the matter. In addition to being a complex subject many Republicans didn’t understand, healthcare struck many GOP members as politically toxic. Free-market health solutions to today’s healthcare problems by necessity involve “taking away” benefits many Americans receive today from corporations and replacing them with a system that voters worry won’t be equivalent. As with that “third rail,” Social Security, many Republicans preferred to allow the broken system to stumble along, offering piecemeal legislative fixes, rather than risk their political fortunes by embracing big change.

This attitude began to change with the turn the century, as health-care prices began to shoot upward and health care again became a pressing American concern. And in fairness to Republicans, at least some of their piecemeal solutions were aimed at establishing the groundwork for larger reform.

Most important was the broad establishment of Health Savings Accounts, one of the highlights of the party’s otherwise uninspiring Medicare “reform” of 2003. The legislation made HSAs available to individuals with an insurance deductible of least $1,100 for individual coverage and at least $2,100 for family coverage. Contributions were tax deductible, and contributions made by employers are not included in an individual’s taxable income. The accounts are portable from job to job and their amounts roll over from year to year. Today, some 3.2 million Americans are enrolled in HSAs, though a smaller number of those accounts are actually funded.

HSAs have shown the power of free-market reform and how it can alter politics. Democrats dislike the accounts since they undermine a government-run insurance program. But at this point, the accounts have become almost too popular for today’s Democratic majority to easily take away. The accounts have helped to give Americans some experience in more financial management of their own care, and they’ve also become a building block upon which Republicans might enact further reform.

As for that further reform, Republicans have started trying to craft a party-wide position on broad, free-market reform. This effort got a real boost in early 2007, when President Bush used his annual State of the Union address to lay out a roadmap for reform. His proposal included sweeping changes to the tax system that would take away the current corporate healthcare subsidy and instead give it to individuals, capping it at $15,000 per family.

President Bush’s proposals unfortunately came too late for Republicans. By 2006 voters were tired of GOP spending and corruption and replaced the party with a Democratic majority, making it impossible for the Republicans to control a healthcare agenda.

That being said, the Bush speech was an important moment. It marked the first time many voters had ever heard of such a conservative plan for more affordable and flexible health insurance and it created a media debate that has kept the issue in front of the public’s eye. Moreover, it served as a clarion call to Republicans and set out a baseline proposal upon which GOP Senators and House members could begin turning the broad Bush ideas into concrete legislative proposals. This has forced the party to confront certain big, thorny policy questions that will be necessary to settle if the GOP wants to move ahead unified on a broad reform proposal.

One example of a behind the scenes fight began last year among GOP senators. On one side were legislators like Arizona’s Jon Kyl who, following President Bush’s lead, argued that an individual benefit should be delivered via a tax deduction. His pitch to his colleagues was that only those who pay taxes should received tax help; to give away tax money more broadly would further distort the tax code and create a de facto welfare/entitlement program.

On the other side were legislators such as Oklahoma’s Tom Coburn, who argued that any individual benefit should be delivered via a refundable tax credit, and thus go even to Americans who don’t today pay taxes. Sen. Coburn, a doctor, suggested this was primarily a matter of fairness, though he has also noted to colleagues that it is a question of politics. To change tax policy in such a way that bars many non-tax-paying Americans from receiving a health benefit would continue to make the GOP vulnerable to the liberal charge that the party was doing little to promote “universal care” or dealing with the uninsured.

Republicans have yet to settle that tax dispute, though when Senator Coburn introduced his own sweeping healthcare reform legislation last year, he garnered notable GOP support. With Democrats in charge, Mr. Coburn never had any shot of getting his bill to the floor, though it has served as a marker and an educational tool to fellow Republicans.

One other thing has bolstered the new GOP push for true, free-market reform: The failure of half-baked “reforms” in states like Massachusetts. Former Bay State Governor and Republican Mitt Romney, drowning under growing healthcare bills in his state, in 2006 signed a health-care bill that was supposed to provide “universal” care. Instead, the legislation failed to reform the regulations that had done so much to raise insurance costs in the state, while forcing individuals to buy insurance and penalizing businesses that didn’t provide it. Two years late, Massachusetts still has hundreds of thousands of uninsured, while state health spending is spiraling out of control.

Not long after Sen. John McCain won his party’s primary, he delivered a long speech offering his own detailed plan for free-market health-care reform. In a sign of how far the GOP has come, and how far it has unified around the concept of consumer-driven care, Mr. McCain’s plan was based on a promise to revamp the tax code and provide individuals with a refundable tax credit to purchase healthcare. It’s taken a long time, but the GOP is finally taking up the healthcare challenge.

The Politics of HealthcareHealthcare today ranks as the top issue for most American voters. The winner of this year’s presidential election will partly rest on who does a better job of convincing Americans of the merits of their plan. The politics of healthcare remain complicated. Both parties have certain natural advantages and certain nagging problems.

The Democratic Party has more cards to play. They face a nation that remains unhappy with a Republican lack of leadership on health care during that party’s tenure in office. Polls show Americans are more willing to trust the Democratic Party on the health question.

They also have a solution that fits far more neatly on that proverbial bumper sticker. That message is clear and concise: Government should step in to pay more of the health-care bill. For many Americans, swimming under doctors invoices, this sounds good. Lost in the debate is how government will pay these healthcare bills—what a greater government role will do to tax burdens or to the quality of care.

The new revamped Democratic health-care message is also carefully calibrated to not worry or offend Americans, as did HillaryCare. The left promises to leave today’s private healthcare system mainly intact and simply “add on” a government insurance option.

Democrats also have the support of powerful interest groups to help them with their cause. At the top of the list are unions, which continue to play enormous roles—in money, message, and manpower—in elections. Some top union officials are simply in line with today’s liberal thinking in their desire for a single payer system. Other union officials have seen what spiraling health-care costs have done to their industries and want the government to relieve employers of these costs. Whatever the motivation, Big Labor is solidly behind Democratic health-care plans.

The Democrats’ problem is that their ultimate vision of government-funded health insurance remains deeply at odds with the wishes of most Americans. While the party has so far not alarmed the country with their more scaled-back plans, that situation might change if Americans were to realize that Democrats’ ultimate aim is a single-payer system. Inspired by their success on the healthcare issue at the polls, Democrats are now being more open about their ultimate goal. In August, Mr. Obama was daring enough to say publicly that he’d prefer a single payer system, and that his hope was to “build up the system we got,” and over time “we may . . . decide that there are other ways for us to provide care more effectively.”

The other Democratic problem is that the more they speak of their plan for a new government insurance program, the more it becomes clear this proposal will not lead to “universal” healthcare.

This became clear in a fascinating debate that raged between the campaigns of Mr. Obama and Hillary Clinton during the Democratic primary. Mrs. Clinton issued a health-care plan that would require every American to purchase healthcare insurance or be hit with a fine. Mr. Obama’s plan only contained that requirement for children because, as he argued in a debate, an “individual mandate” would only financially penalize those who might not be able to afford to buy health insurance in the first place. What Mr. Obama was in fact admitting was that a new government program won’t in fact lead to “universal care,” and that a mandate would simply force Americans into a highly regulated and price-controlled system where government redistributes income and dictates coverage.

Conservatives have the better ideas and they also have on their side the fact that American remains a center-right country that values choice and individual control, dislikes high taxes and distrusts government and bureaucracy.

Yet the Republican Party will have to be much savvier about turning its healthcare ideas into political successes. Having squandered Americans’ trust, they now have to gain that back by being bold on an issue that only recently has started to become a GOP priority. The reform they advocate is also big, the sort of change that naturally makes voters nervous. Having waited so long to talk about this, they’ve not yet done enough to educate Americans about their vision. At least some in the party don’t yet understand the question, or how to proceed.

Republicans will need to do several things if they don’t want to risk further jeopardizing what remains the world’s most innovative private health-care market. For starters, it has to explain how reform would work to average Americans. It needs to reach into people’s homes and compare what they have now with what they’d get under a GOP plan. It needs to go back to basics, explain to voters the nature of “insurance” and why today’s healthcare system can no longer be termed a functioning “insurance market. It needs to preach responsibility and explain that along with that responsibility comes more control, more choice and lower prices. It needs to explain that broad health-care reform isn’t just about today’s problems, but future ones—that saving in an HSA doesn’t just help pay current health bills, but one day will allow a senior citizen to purchase assisted living or nursing care.

Republicans also have to alert more Americans to the true Democratic strategy. They need to put Democratic attempts to increase the SCHIP and Medicare programs in the context of the party’s wider desire to suck everyone into a government program. They need to talk about the problems that accompany existing single-payer programs, such as Medicare: lack of quality care, chronic underfunding and government bureaucracy.

What will happen after this year’s election? If John McCain should win, the country will likely see more years of health-care gridlock. The Congress is almost certain to remain in Democratic hands and its leadership will refuse to act on Mr. McCain’s proposals. Mr. McCain, in turn, is likely to veto Democratic moves toward more government care.

Yet even an Obama win doesn’t guarantee he will get his new government insurance program. Democrats remain deeply divided on the specifics of health-care reform and might prove unable to cobble together legislation that the party will support. Republicans, too, have a decent chance of retaining the numbers they need to filibuster legislation in the Senate and would undoubtedly stymie an Obama plan.

The next few years will instead likely serve as an opportunity for both sides to sharpen their positions and further argue their case with the American public, with ensuing elections serving as a referenda on where voters stand. This is an opportunity for conservatives to “own” the healthcare issue.

As an interesting side note, Harry and Louise are back. This time, instead of attacking one approach, the couple will simply be starring in ads in which they remind the country they are still waiting for better healthcare and urge government to act. The couple may have to wait some time to get their wish.

Prepared for Hillsdale College’s Free Market Forum, “The Role of Markets and Governments in Pursuing the Common Good,” Panel Topic: “Markets and Politics,” September 26, 2008.